1 and Co-Occurring Conditions Sherrie M. Vavrichek, LCSW-C Behavior Therapy Center of Greater Washington Silver Spring, MD Anxiety and Depression Association of America Annual Conference, April, 2014 Chicago, IL 2 Disclosure The speaker is a senior clinician at the Behavioral Therapy Center of Greater Washington. She has no relevant financial or nonfinancial conflict of interest relationship to disclose. Ms. Vavrichek is the author of The Guide to Compassionate Assertiveness: How to Express Your Needs and Deal With Conflict While Keeping a Kind Heart Summary of Presentation 3 1st Half : What’s new in the field of ASD Current understanding Treatment interventions 2nd Half: Case Example, Audio Recordings 1) Lee, Age 19 2) Lee, Age 24 3) Lee’s Parents Q&A 4 Objectives 1. Identify the three disorders in “ ” DSM-V now under ASD 2. List two common co-occurring conditions 3. Describe one research finding 4. State three clinical interventions DSM-V 5 Autism Spectrum Disorders (ASDs) 299.00 Subsumes: Autism Asperger’s Syndrome Pervasive Developmental Disorder NOS 6 Symptom Clusters 1) Social: Communication/ Interactions 2) a. Restricted Interests and/or b. Repetitive Behaviors Other Criteria 3) Present by early childhood 4) Causes functional impairment 7 ü With/Without Intellectual Disability ü Known Medical or Genetic Condition ü Co-Occurring Neurological, Mental, and Behavioral Disorders 8 ü Anxiety Disorders, including phobias ü Obsessive Compulsive Spectrum: OCD, Scrupulosity, Tourettic OCD, Tourette’s Syndrome, Tics, Body Focused Repetitive Behaviors (BFRBs) ü ADHD, Learning / Language disabilities ü Depression 9 Social communication: 1. support 2. substantial support 3. very substantial support Restrictive interests/repetitive behaviors: 1. support 2. substantial support 3. very substantial support 10 Autism Spectrum Disorder 299.00. Associated with Obsessive Compulsive Disorder 300.3 and Excoriation (Skin Picking) Disorder 698.4 Without Intellectual Disability Requires support for deficits in social communication and support for repetitive behaviors. 11 DSM describes what ASDs look like on the outside, But what is happening on the inside? The place to start: how does the “autistic brain” work? 12 Current Theories Uneven or disruptive development in certain parts of the brain, or …inefficient communication between brain regions, or both, as reflected in a particular cognitive style. Cognitive Styles 13 Empathizers: big picture, focus on people, relationships, emotions, and complex social interactions, process Systemizers: detail oriented, analytical thinkers, good at mechanical reasoning, able to organize, sequence objects / facts, seek out rules and patterns, at their own pace, seek completion (S. Baron-Cohen) 14 Continuum of Cognitive Styles Cognitive Strengths 15 Steven 6 y/o Ainan Cawley Wiltshire “word thinker” “visual realistic” Guess who? “pattern thinker” 16 Intense focus, logical reasoning, attention to detail 17 Personal Strengths Refreshing honesty/openness, sincerity Strong sense of ethics and integrity, want to do the right thing—tend to be scrupulous Passion, engagement, and knowledge or skill in certain areas 18 Despite Strengths, Vulnerabilities Make Life Difficult 19 Sensory/motor – hypo-, hyper- sensitivity, clumsiness Language - Concrete, literal, some idiosyncratic vocabulary, phrasing Cognitive - Problems with “self- monitoring” and Theory of Mind (ToM) Emotional – Overwhelmed by strong emotions, limited coping skills…. Overwhelmed 20 by Strong Emotions Feel things deeply Freeze, fight or flight reactions 21 Combined Vulnerabilities Sensory Issues + Concrete Language + Cognitive “Unevenness” + Emotional Dysregulation = Social Challenges Perfect Storm Social Challenges 22 Difficulty joining in, tuning in, participating; tend to seek comfort by turning inward Can be hard to be around. May be 23 blunt, insensitive to needs of others; may tease, but are rarely aggressive --almost always in reaction to feeling wounded by others Most are lonely, yearn for friends. Are naïve--can be victimized, exploited, bullied. (Shapira, Washington Post) Life With ASD is Not Easy 24 Confused, criticized, misunderstood, unappreciated, frustrated, hurt, angry Are often underachievers, want to do better Have strong desire to be supported and understood. Clinicians and researchers are trying to help. 25 Clinicians to meet the needs of growing ASD population Why People Seek Help 26 Children-often behavioral or anxiety problems. Many have had ABA, speech / occupational therapy, and special education services Teens-social and emotional distress, Concerns about college Adults-relationship, job issues, may be undiagnosed What Can Help: 27 Structured Sessions Positives at beginning of each session Review homework Prepare schedules, check-lists Invoke social rules Increase Motivation: Point systems/ allowances, Premack New Homework-Write it out for them —apps? 28 Visuals Emotional Support 29 “You are just as good a person as anyone else” “I’m on your side; I believe in you” “Let others see you the way I do” “That was such a smart idea!” Cognitive Reframing 30 (To manage depressive rumination) “You did the best you could at the time” “You were younger then…you’re older and stronger now” “They didn’t understand / know better” CBT Skill Development 31 Emotional regulation Conversation skills Coping skills Problem-solving skills Also need help with… Grooming/modesty/self-care skills Scripting 32 Scripting – Give them words to memorize and repeat to themselves. Builds on strengths: visuals, memory. Protects them from getting caught off guard. Examples: Social Stories (Carol Gray, see Sohn (2005) in References Coping (index) cards on mirrors, in notebooks, put into devices 33 Scripts About Self / Others “Like everyone else, I have strengths and weaknesses” “I can develop inner strength and tame my emotions” “Being flexible is good for me—I can learn patience” 34 Scripts About Rules Some things are not a choice I can’t always get what I want— but I can handle it My parents have to be in charge in order to do their job Research 35 www.sfari.org www.nimh.gov 36 Etiology Many questions remain. But now established: ASDs caused by problems that occur before birth. Environmental toxins, e.g., link between pregnant mother’s use of seizure meds (valproate) and autism in offspring. R/O vaccines or other factors after birth Genetic Mutations 37 The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and Extra, deleted, or then insert it again. rearranged copies… 500+ genes 9 chromosomes Mutations that can cause ASD or traits can occur during formation of sperm/eggs or during fertilization. The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then Potential risk: older insert it again. parents, esp. fathers. 38 Impact on Brain Cells Environmental and/or genetic mutations affect fetus’ developing neuro-endocrine system– mirror (ToM, empathy) spindle neurons (inter- regional communica- tion) being investigated Focus on synapses and neurotransmitters: connectivity between regions of the brain— (Uddin) 39 No ASD silver bullet…but: ü Depression, Anxiety, OCD: SSRIs ü Anger outbursts: Neuroleptics ü ADHD: Stimulants ü Tics / TS / BFRBs: Alpha-2 Agonists Promising research: oxytocin nasal spray, N-AC Reasons For Optimism 40 Brain plasticity: The brain is a learning machine Developmental process--maturation People w/ASD can: build on strengths learn new skills be happier 41 Case Study: Lee Began Tx Age 16, Now 24 Basic Information 42 About Lee High functioning autism OCD – Contamination (bathroom, touching trash cans) Emotional dysregulation (when younger, tantrums, some aggression) 43 Interview #1-Age19 What Can You Tell Me About AS? I’m smart. Interested in computers, TV; aware, sensitive because of it. I could be a loner? What does that mean, to be a loner? It could be hard-friends-may disagree on things. But I need to remember that people can respect each other even if they disagree. Learned it in school. I would do well to remember it. Things you’re good at: 44 I’m good at solving puzzles, chess, sudoku. Still working on it. Ever gotten in trouble? Earliest memories-hit other people when younger. First I didn‘t know, then feelings were so strong, so young, and I couldn’t help it. It took me a while, longer to get used to things. I knew I had potential to be smart, could become more smart but more slowly— do things at my own tempo. …also good at art, music, math, spelling Described memories of unusual math 45 and spelling abilities as a young child I kind of liked the letter X and the color green—my eyes are green—liked to carry green things, esp. X around with me. Things I like about you: kind, honest, caring. Pleasure to work with you. Wow…that’s… great. Felt that way ever since I’ve known you…happy to work with you & family to have things go smoothly for you. 46 Anything in our work that’s been helpful? Write down good things--be happy, could help. Chart and point system-has that helped? My life has been going great ever since we started doing it. Your father said you remember most of the things, even without the chart. I think a schedule is a good thing. I use a schedule, too. 47 (Began to talk but…) his foot hit a tippy table, it fell over and set off alarm clock. He got upset--concerned about what people would think. Discussed it a bit…Agreed to explain that it was an accident. Asked for more advice from Lee on how adults can help people w/ ASDs. Find out what the kid likes to do. No. 1 priority. Then to practice skills.